Medicare/Medicaid/Insurance does not pay for an item simply because a patient needs it and has a doctor’s order. Unfortunately, some items are not covered whether a health care provider writes a prescription or not.
Medicare has specific guidelines. Most insurances, especially Medicare supplements and Medicare replacement plans, follow Medicare guidelines. Medicaid varies; sometimes coverage follows Medicare guidelines and sometimes not.
Bathroom equipment such as shower seats, transfer benches and grab bars are not covered by Medicare, and are seldom covered by insurance.
If a recipient qualifies, it is possible Medicare will pay for a hospital bed, trapeze, walker, wheelchair, oxygen, CPAP/BiPAP, nebulizer and other equipment that the person needs at home. Medicare also may cover catheters, diabetic strips, wound care and ostomy products if a recipient qualifies and the DME provider has the necessary documentation from the ordering physician. Enteral feeding products are covered if proper documentation is received and the supplements are the sole source of nutrition for a person who is unable to swallow.
Face-to-face visits required
Effective with passage of the Affordable Care Act, most pieces of medical equipment require a face-to-face visit for coverage. If a person feels they might need a piece of equipment, it is important to make an appointment with a health care provider to discuss the need. Justification for the product must be included in the patient’s notes.
It is also extremely important to let a health care provider know at each visit the medical equipment or supplies you are using. Just as a list of medications/supplements needs to be discussed, so does your medical equipment and/or supplies. Most payer sources require evidence, through patient notes, that equipment and supplies are needed and are being used.
Medicare billing changes
Due to the Affordable Care Act, Centers for Medicare & Medicaid Services has implemented competitive bid rates throughout the United States. Competitive bid rates is the amount of money Medicare now pays toward medical equipment/supplies. The new rates do not always cover the cost to acquire equipment/supplies. If the cost is not covered, the DME provider will bill items non-assign, which means the Medicare recipient pays up front and Medicare reimburses them if documentation exists to show they qualified for the equipment or supplies.
Read the fine print
Medicare replacement plans may have different coverage criteria than standard Medicare. Medicare supplemental insurance follows Medicare guidelines. Insurance policies vary. It is important to read the fine print to know exactly what is covered with each plan.
Before making any changes with your Medicare Part B coverage (switching from traditional Medicare to a replacement plan — or switching replacement plans, etc.) — be sure to talk to your DME provider. If you have any equipment being rented from Medicare, or supplies being billed to Medicare, changing plans may affect payment. And, always ensure your DME provider has the most recent Medicare/Medicaid/Insurance information.
Specific guidelines and verbiage are required for most pieces of durable medical equipment. It is important to remember a doctor’s order does not guarantee payment. Patients should contact their durable medical equipment supplier with specific questions regarding coverage of a piece of equipment.
- By BLESSINGOSPITAL.ORG